Edmonton, Alberta — Commanders in the Canadian Armed Forces (CAF) receive periodic reports on the condition and risk of breakdown of vehicles, ships or aircraft, but the organization does not have an equivalent for that most important resource of all – its soldiers. Major Daniel Crumback is working on creating just that.

“Army commanders rely on Vehicle Off Road reports to identify how many of their vehicles are broken or require maintenance. When I proposed that we could employ this concept for human beings, immediate interest was expressed by many commanding officers,” said Maj Crumback, the Physiotherapy Regional Practice Leader for Western Canada.

Maj Crumback is currently completing a Master’s degree in Rehabilitation Science from the University of Alberta and hopes to identify a cluster of tests that can predict quadrant-based musculoskeletal (MSK) injuries, to be called the Quadrant-Based Injury Prediction System (QBIPS).

“Quadrants, in this case, are used to refer to local injuries that commonly affect the surrounding area or region such as a low back dysfunction that affects the pelvis, hip, and knee,” noted Maj Crumback, who developed three quadrant-based training systems – the Functional Integrated Training (FIT) programs – which include the Upper Quadrant (UQFIT), Lower Quadrant (LQFIT), and Spinal (SFIT) programs. The goal of these programs is to progress personnel limited by MSK injuries from rehabilitation to performance-based training. The FIT programs have been trialed at three CAF bases and resulted in significant functional improvements in all participants.

About a decade ago, Maj Crumback began to develop the FIT series while he was the Physiotherapist with the Canadian Special Operations Regiment in Petawawa to create efficient and effective exercise-based programming for CAF personnel. The FIT series is a collaborative program involving the CAF’s physical rehabilitation team and the Personnel Support Programs (PSP) Fitness staff at six bases in Western Canada, with plans to roll out into Atlantic Canada in the fall of 2016. FIT is now known as Rehab to Performance (R2P).

“R2P is a collaborative approach between physio and PSP Fitness,” said Rick McKie.

CAF National Fitness Manager with PSP in Ottawa. He noted the many benefits of the two organizations working together “towards the common goal of returning our client/patient back to work or their ‘new normal’”.

Data collection for Maj Crumback’s QBIPS study began in August 2016 and will evaluate the ability of a movement-based clinical test cluster (19 tests) to predict quadrant-based injuries within the following six to 12 months in CAF personnel. By identifying the at-risk population through this process, the researchers can then use the R2P programs for injury prevention purposes.

“One cannot develop an effective injury prevention system without being able to identify the at-risk population,” Maj Crumback said. “My goal will be to employ my R2P programs to prevent injuries and improve performance instead of using it as a rehabilitation program.”

“I’ve been working with lead researchers in the United States military, but currently we are the only one approaching prediction from a quadrant-based perspective,” said he added. “There are studies that show movement-based tests can predict future injury but these studies can’t tell you which area will be affected or when. After reviewing their latest research, the U.S. military is considering moving to a quadrant-based approach as well.”

Current CAF physio treatments focus on relieving pain and restoring mobility, Maj Crumback explained, but this does not return tissue to a state in which it can withstand the stresses of training and operations. That is why there is a significant re-injury rate with CAF members. The only way to ensure that the affected tissues are able to withstand these forces is through an extensive quadrant-specific exercise program. This programming is well beyond what CAF is now able to provide within its physiotherapy clinics.

“The programs that physiotherapists prescribe do not tend to be long or hard enough to return soldiers back to their occupation without the risk of re-injury,” Maj Crumback said.

Norm DeNault, Physiotherapy Acting Team Lead at 1 Field Ambulance Clinic in Edmonton added, “The R2P programs bridge that gap between rehab and performance, ensuring our tactical athletes can resume their full duties in the same way a professional athlete can be ready on game day.”

“It’s great to prove you’ve predicted risk, but ultimately, we need to prove that the R2P programs decrease the risk of injury and improve performance,” Maj Crumback said. Ultimately, he added, this will result in more trainable and operational personnel available to commanders, decreased re-injury rates, decreased load on Health Services resources, and an improved quality of life for personnel.

He is hopeful that the research will result in a positive contribution to the Canadian Army Integrated Performance Strategy (CAIPS). CAIPS is intended to promote the adoption of a performance-oriented, health- and fitness-based culture in order to increase readiness by generating better prepared and more resilient soldiers. CAIPS has a website called MISSION: Ready that supports the strategy at strongproudready.ca.

“Major Crumback’s research is seen as a potential contributor to the Canadian Army Integrated Performance Strategy,” said Brigadier-General Wayne Eyre, incoming Deputy Commander of Military Personnel Command.

Quadrant-Based Injury Prediction System Study

Maj Crumback and his team of 16 are studying 500 healthy CAF members from several Edmonton-based units, including 1 Service Battalion; Lord Strathcona's Horse (Royal Canadians); 3rd Battalion, Princess Patricia’s Canadian Light Infantry; and 1 Combat Engineer Regiment. Participants who met the inclusion criteria will complete a baseline questionnaire that includes basic demographics such as age and trade, smoking history, fitness habits, and past medical history, then complete a 19 movement-based test cluster and be monitored for six to 12 months via monthly e-mail questionnaires.

He expects his thesis to be complete by summer 2017, after which a second phase of the study will begin. Based upon the first phase’s results, he expects to be able to identify at-risk individuals using an algorithm that will assign them a risk score that will indicate their risk of injury for each quadrant (e.g., six times the risk for an upper quadrant injury) and when this injury could be expected to occur (e.g., in the next three months). During the second phase, researchers will then have at-risk participants complete the corresponding quadrant-based FIT program, and then re-assess their risk of injury to determine changes in modifiable risk.

A third phase of the study will look at how re-injury rates will be affected and how risk scores might change over a five-year period.

Maj Crumback, who joined CAF in 1980, first experienced military physiotherapy as a patient recovering from injuries sustained while he was deployed in Germany.

“I witnessed physio and I thought, ‘This looks interesting to me.’ And I felt that it had great potential but I wasn’t impressed with it. I thought, ‘This could be so much more than what I just experienced if it were more coordinated.’”

He was selected for a Training Plan for Non-Commissioned Members and completed his undergraduate degree in physiotherapy at the University of British Columbia in 1994 before retiring under the Forces Reduction Program in 1996.

He later worked in private clinics in Canada and the U.S.

“I returned from the U.S. and evaluated all the things I’ve done and what I really enjoyed the most was the military,” he recalled. “So I re-joined in 2004.”

He has since served as a Physiotherapy Officer in Afghanistan and at Canadian Special Operations Regiment. Maj Crumback is currently Physiotherapy Regional Practice Leader for the Western Region. There, he said, he found the right mix of people to help drive his work forward.

“I was posted to Edmonton and all the right people came together. Right place, right time.”

And interest is growing outside of Canada as well.

“I recently presented on quadrant-based training of Tactical Athletes in Beijing at a performance summit sponsored by the Chinese Olympic Committee,” Maj Crumback added. “New Zealand sent a member of their military to attend our four-day FIT course in Edmonton with a view to employ the R2P concepts with the NZ military. It is an honour to work with some of the best minds in MSK injury prediction. The decision to be a physio and to rejoin the military was a good one.”